Practicum Assessing Client Progress Essay.

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Practicum Assessing Client Progress Essay.

 

Progress Notes and Privileged Notes: Comprehensive Psychiatric Client Family Assessment for Client K.S.

  1. Progress Note for Ms. K.S.

In the form of a SOAP note according to Cameron and Turtle-Song (2002), the following is the progress note after psychotherapy for patient K.S. diagnosed with depression. She meets this diagnosis as per the criteria in the DSM-5 (APA, 2013). She is undergoing cognitive restructuring through the nonpharmacologic psychotherapeutic strategy of cognitive behavioral therapy or CBT (Corey, 2017). The treatment is done in weekly one-to-one sessions during which the psychiatric-mental health nurse practitioner (PMHNP) writes down both progress and privileged notes (Wheeler, 2014). Practicum Assessing Client Progress Essay.

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Subjective

The chief complaint of patient K.S was feeling disregarded by her father, feeling sad and abandoned, and feeling unwanted by her biological father and stepmother. She feels lonely and withdrawn and does not want to engage in pleasurable activities together with others. She dropped out of school, is unemployed, and spends most of the time locking herself away from others. She has two elder sisters with whom she lives after they left their father’s house because their stepmother was abusive. She uses opioids to cheer herself up and make herself forget her sadness. She complains of occasional palpitations and also an episode of back pain sometime ago.Practicum Assessing Client Progress Essay. She denies allergies or any other medical problems. She also denies any surgical history. She denies any previous mental health problems. Her deceased biological mother had depression and bipolar disorder. No other person in her family has mental health problems. She denies any previous clinical emergencies, but details being abused (“disciplined”) as a child after her parents divorced at age five. She describes her childhood as miserable. She however denies any suicidal thoughts or thoughts of wanting to harm others.Practicum Assessing Client Progress Essay.

Objective

Patient K.S. appears appropriately dressed with a stable gait. Her speech is low in content and she tends to avoid eye contact. She is definitely melancholic and shows fair insight into her condition. She is not cognitively impaired, but demonstrates suspicion and anxiety. She looks wasted, although she has a normal body mass index of 20.7 kg/m2 on calculation. During therapy she maintains long periods of silence, but when shown empathy she opens up on her sorrows and past mistreatment as a child. She is a good candidate for psychotherapy and is slowly bonding with the therapist. Opioid testing of her urine in the laboratory confirmed that she has been abusing opioids. Her mood is dysphoric, but she has fair insight into her illness.Practicum Assessing Client Progress Essay.

Assessment

The information revealed from the subjective and objective data above shows that patient K.S. is withdrawn and does not enjoy the pleasurable activities she enjoyed previously. She is sad and feels pity for herself. She also feels worthless and rejected. Her mood is dysphoric. In all, she meets all the criteria for a diagnosis of depression (major depressive disorder or MDD) according to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders or DSM-5. These include (APA, 2013):Practicum Assessing Client Progress Essay.

  • Diminished interest in pleasurable activities for the whole day.
  • Depressed mood most of the day as shown by sadness, emptiness, and hopelessness.
  • Psychomotor retardation and feelings of worthlessness.
  • Reduced ability to concentrate, as shown by her dropping out of school.
  • Impairment in social and other areas of functioning caused by the clinical expression of the symptoms.
  • The symptoms cannot be attributed to another medical condition or substance use.Practicum Assessing Client Progress Essay.

The differential diagnosis for patient K.S. includes (i) attention/ deficit hyperactivity disorder or ADHD (ii) adjustment disorder with depressed mood (APA, 2013).

Plan

Ms. K.S. is started on psychotherapy by means of weakly CBT sessions with the aim of remodelling her thoughts and making them influence positive behavior. Evidence-based practice (EBP) suggests that the best management for depression is a combination of psychotherapy and pharmacotherapy (Fekadu et al., 2017). For this reason, the complete plan will be:Practicum Assessing Client Progress Essay.

  1. Start weekly CBT for 16 weeks
  2. Start sertraline (Zoloft) 100 mg qd for one month (Stahl, 2017).

The plan of treatment will then be reviewed after four weeks (the follow-up time). This will especially have to do with the pharmacologic management, depending on the patient’s response.

  1. Privileged Note for Ms. K.S.

Psychotherapy notes are also referred to as privileged notes and belong to the therapist. They are not part of the conventional medical records that other clinicians may rightfully have access to. Even the patient cannot legally access privileged notes taken down by the therapist. They help the therapist in making therapy decisions regarding the patient. Items in privileged notes cannot be part of the normal clinical records of the patient since they may contain inappropriate content not suitable for other care givers/ clinicians or even payers. The following are some of the privileged notes the therapist may write down in the case of client K.S:Practicum Assessing Client Progress Essay.

  • I think this girl may abusing more drugs than the opioids she says she has been using. I may have to probe her further on this even though she seems reluctant to talk about this.

It is difficult to believe that a father can just let her three girls go live alone without getting concerned and trying to get them back in his house. I think there is more to this case than the client is telling me. I need to find out the rest of this case.Practicum Assessing Client Progress Essay.

Learning Objectives

Students will:

  • Create progress notes
  • Create privileged notes
  • Justify the inclusion or exclusion of information in progress and privileged notes
  • Evaluate preceptor notes

To prepare:

  • Reflect on the client family you selected for the Week 3 Practicum Assignment. (see below)

 

Assignment

 

Part 1: Progress Note

Using the client family from your Week 3 Practicum Assignment, address in a progress note(without violating HIPAA regulations) the following:Practicum Assessing Client Progress Essay.

  • Treatment modality used and efficacy of approach
  • Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the treatment plan for progress toward goals)
  • Modification(s) of the treatment plan that were made based on progress/lack of progress
  • Clinical impressions regarding diagnosis and or symptoms
  • Relevant psychosocial information or changes from original assessment (e.g., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job)
  • Safety issues
  • Clinical emergencies/actions taken
  • Medications used by the patient, even if the nurse psychotherapist was not the one prescribing them
  • Treatment compliance/lack of compliance
  • Clinical consultations
  • Collaboration with other professionals (e.g., phone consultations with physicians, psychiatrists, marriage/family therapists)
  • The therapist’s recommendations, including whether the client agreed to the recommendations
  • Referrals made/reasons for making referrals
  • Termination/issues that are relevant to the termination process (e.g., client informed of loss of insurance or refusal of insurance company to pay for continued sessions)
  • Issues related to consent and/or informed consent for treatment
  • Information concerning child abuse and/or elder or dependent adult abuse, including documentation as to where the abuse was reported
  • Information reflecting the therapist’s exercise of clinical judgment

Note: Be sure to exclude any information that should not be found in a discoverable progress note.

 

Part 2: Privileged Note

Based on this week’s readings, prepare a privileged psychotherapy note that you would use to document your impressions of therapeutic progress/therapy sessions for your client family from the Week 3 Practicum Assignment.Practicum Assessing Client Progress Essay.

In your progress note, address the following:

  • Include items that you would not typically include in a note as part of the clinical record.
  • Explain why the items you included in the privileged note would not be included in the client family’s progress note.
  • Explain whether your preceptor uses privileged notes. If so, describe the type of information he or she might include. If not, explain why.

 

 

Comprehensive Family Assessment from Week 3

COMPREHENSIVE CLIENT FAMILY ASSESSMENT2Comprehensive Client Family AssessmentThe paper is meant to complete a comprehensive assessment on the family that Iinterviewed in one of my clinical rotations, a psychotherapy session in week 3. Without violatingHIPPA regulations, client’s identity is reserved and changed to a different initial and name due toconfidentiality. This paper will also present a genogram of the client retroactive to threegenerations.Demographic information: This is the Smith’s family. Mr. S.M, (Father) is an AfricanAmerican male, married to Mrs. J.S., the (Stepmother) of three biological girls of Mr. S.M., tothe three adult girls; Ms. G.S. (First Daughter), A.S. (Second Daughter), and K.S. (YoungestDaughter). Father is employed works full-time, spouse is a stay home mother. Two daughters areemployed and A.S., the youngest of the daughters is unemployed and current in college. Thesmith family has been having some blended family adjustments and Substance abuse issues on theiryoungestdaughter.Presentingproblem:Per K.S., (youngest daughter), “My father does not regard me with equal value, or even accept me ashisdaughter.”Per G.S. and A.S., “We are disappointed with our father and stepmother.”Per Mr. Smith (Father) “My youngest daughter is addicted to opioids and blamed her drug use onme.”History or present illness: Following the chaos and misunderstanding in the family, the threedaughters, ages 22, 20, and 18year old moved out of the family home. According to them, “step-mother is aggressive and verbally abusive. The girls stated that their stepmother has repeatedlyabused them and ordered them to move out of the house. Shortly, after moving out the youngest

COMPREHENSIVE CLIENT FAMILY ASSESSMENT3daughters started isolating self and abusing opioids. Per K.S. (The youngest daughter) “that theway out to easy my pain.” Family seek for help client, when K.S., started isolating herself fromthe sisters and staying in bed more often, complaint of sadness and cry. Following a detailedinformation regarding concerns related to the stepmother parenting style and current disciplinarystrategies, a referral was made for psychotherapy session. The family is concern of theiryoungest daughter mental status. The health examination will be focused on Ms. KS., youngestdaughter.Past psychiatric history:Client (K.S.) has no prior history of mental health issue.Medical history: Medical history would be obtained for Mr. and Mrs. Smith and other threedaughters. Both paternal and maternal family medical history is also needed.Substance use history: The youngest of the daughters, has opioid use addiction. Father statedthat he occasionally use alcohol.Developmental history: Client had a normal developmental milestone. At age 5, her parent’shad a divorce and it was traumatic to client, per client it affected her school grade. Client dropout of high school and currently working towards acquiring her GED. Client lived with father,stepmother and two siblings up until 17years, before moving out of the family home with herother two sisters. Client relationship with his father became even more soiled after dad marriedto her stepmother. Client described being disciplined as a child as “misery.” She was able torecall a detailed description of how she was disciplined as a child. Additionally, she shared herbelief that “it is the parents’ job to discipline their children as they see fit” (Laureate Education(Producer), 2013a).Family psychiatric history:Practicum Assessing Client Progress Essay.

COMPREHENSIVE CLIENT FAMILY ASSESSMENT4Father has no mental health historyBiological Mother has Depression and Bipolar disorderSiblings: Two sisters are healthy, no mental Health problem reported.Psychosocial history: Mr. and Mrs. Smith (Stepmother) lives together, while the three daughterslive together. Father is employed, stepmother is stay home mother and the first and seconddaughters completed high school and currently employed. Client, the youngest daughter droppedout of high school, and is in verge of getting her GED. No religious preference stated and nolegal issue with, extended family interactions and involvement, parent’s educational status, andnone of the family members has legal issue with the law.History of trauma and abuse: Client denies head trauma or sexual, client reported verbal andphysical, and emotional abuse.Practicum Assessing Client Progress Essay. Neither parent did not disclosed any history of abuse howeverthis case need further discussion.Review of systems:Constitutional: BMI 20.7kg/m2. No recent weight changes.Eyes: Sclera white, clear, no eye discharge, no vision changes reportedEars: No tinnitus or hearing loss, no drainage from ear, no pain reportedNose: No difficulty breathing, rhinitis or epistaxis, no runny nose.Neck: Symmetrical, no difficulty swallowing, no pain or swelling.Skin: Color of skin is appropriate for ethnicity, dry, intact. No skin lesion, or edema noted, nailbed smooth edges.Respiratory: Denies shortness of breath, no cough, no dyspnea, exertion, and reportedCardiovascular: Ocassional palpitations, capillaries refills < 3 seconds, No chest pain, pressure,orthopnea, murmurs, or arrhythmias reported.Practicum Assessing Client Progress Essay.

COMPREHENSIVE CLIENT FAMILY ASSESSMENT5GI: Denies report of nausea/vomiting, diarrhea or constipation, poor appetiteGU: No dysuria, nocturia, hematuria reported.Endo: denies night sweat, no report of hypoglycemia/hyperglycemia reported.Neuro: Alert/oriented x 3, no headaches, no dizziness, syncope, numbness & tingling. Gait isstable, weakness, delusional thought, or head trauma. No change in bowel or bladder controlreported. Reported unexplained upper back pain 7/10MUSC: No arthralgia, arthritis, limitation in range of motion or back pain.ALLERGIES: No known allergies to food or drug, no history of asthma, hives, eczema.Physical assessment: Ms. K.S. is alert/oriented x 4, speech is clear, coherent, cognition intactNo physical limitations or chronic condition noted. Well groom, hygiene good, fingernailspinkish, well file, and clean, Skin color normal for ethnicity, hydrated. Client is ambulatory, nophysical impairment noted.Mental status exam: Client is alert is alert/oriented x 4, cognitive intact, speech clear, flow ratenormal, able to articulate, mood congruent.Practicum Assessing Client Progress Essay. No signs of illogical or impaired thought process isnoted when interacting with either parent appropriate, emotion is noted and client wascooperative at session and participated well, no affection towards each other duringpsychotherapy, insight is fair. Denies hearing voices or seeing things no other person can understand.Level of participation: Client participated actively in the therapy and was able to share the impact herparents had on her. Mood: client report feeling depressed and isolated from family and friends sometimes.Client denies Suicidal thought or denies thoughts of harming others. Client stated that the way to copewith her depression was to engage in drug use, however, her older sisters is the strong support system.Speech: Normal tone and respond to questions appropriately and at a normal flow rate.Differential diagnosis:

COMPREHENSIVE CLIENT FAMILY ASSESSMENT61.) Differential diagnosis (DDX): Her diagnosis of depression aligns with the DSM-5 based onthe symptoms the patient reported which includes sustained feelings of sadness, lack ofinterests in activities she once liked, fatigue, difficulty in concentrating, trouble in sleeping,and loss of appetite (American Psychiatric Association, 2013). Efficacy of the Existential-Humanistic Method The existential-humanistic approach holds that patients can make theirchoices as well as self-awareness. When applying this approach to deal with the patient, itwill enable the patient to find her philosophical meaning while facing her depressioncondition. Based on the method, the2.) Rule out V61.22 Encounter for mental health services for perpetrator of parental childpsychological abuse (APA, 2013).Case formulation:Practicum Assessing Client Progress Essay. The Smith presented chaos, miscommunication, bitter feelings andverbalize their commitment to completing the ACS required family therapy that involvementcreating a stronger, trusting family. Financial barriers may impede the family’s ability to becompliant with parenting classes and should be analyzed for risk, benefit, and consideration of abetter suited intervention. Learned behavior, cultural influence, and lack of insight as it relates toemotional wellbeing seem to be the couples’ weakness. Mr. Smith verbalizes belief in ridgedboundaries when it comes to disciplining his children and is supported by Mrs. Smith(Stepmother). There is no evidence of suspected physical abuse at this point however a detailedaccount of the ACS workers rationale for mandating parenting classes is needed. The daughtersinvolve in this case are adults, at this point the focus is to encourage therapeutic communication,and work towards healing process.Treatment plan:1.) Obtain additional clinical information in areas mentioned above.Practicum Assessing Client Progress Essay.